It has been difficult for everyone to stay healthy and connected during the COVID-19 pandemic, but especially for older, homebound patients and their caregivers. Fortunately, a program developed by the Geriatrics and Supportive Care Team at the University of Texas Health Science Center at San Antonio effectively integrates health workers into the community (prosecutors of health in Spanish) in the range of patients to improve health. Thanks to the program, annual visits by seniors with type 2 diabetes, dementia and other health problems in underserved areas of Bexar County, Texas, have doubled from pre-pandemic levels.
The program described on July 24 in Annals of Family Medicine, resulted in a 17% reduction in hospital admissions and an 11% reduction in emergency department visits among patients cared for at home. The majority of patients who visit the office are over 85 years old.
“Promoters act as a bridge,” said Neela K. Patel, MD, MPH, CMD, FAAFP, associate professor of family and community medicine at UT Health San Antonio and chief of the division of geriatrics and supportive care. “They communicate to the patient who we are and what our role is and how we are trying to support them, and they communicate to us the concerns of the family and the patient. This helps us respect the patient’s choices and values and provide care that is respectful from the patient’s perspective, not from ours.”
Visits are not usually made by a prosecutor (female CHW) and doctor together. When the doctor sees that the patient needs help outside of medical care, such as with various types of community resources, a promoter is assigned to help with these issues.
“The patients we serve may need help with caregivers, with benefits arrangements, with medications, with transportation or with starting Meals on Wheels,” Patel said. “We ask the promoter to either go before us or between our home visits.”
Patel, the study’s senior author, holds two faculty chairs at UT Health San Antonio: the Joe R. and Teresa Lozano Long Chair in Geriatrics and Community Aged Care and the Glenn and Anne Biggs Distinguished Chair in Alzheimer’s Care.
Older patients may have difficulty remembering and following the doctor’s advice.
“If the individual’s diabetes is not improving or the person caring for a person with dementia has behavioral issues and all of that, then the promoter goes and visits them and gives us the inside story,” Patel said. “It really helps us take better care of our patients.”
Preventing emergency department visits and hospital stays is one of the community health worker’s greatest roles.
“Basically, promoters have the trust and the relationship, and they reinforce with patients and caregivers that they are available 24/7,” Patel said.
When a patient or caregiver has difficulty reaching the office, he or she has direct contact with the promoter.
“A caring physician may let us know that the patient is very sick but doesn’t want to go to the emergency room,” Patel said. “The doctor asks if we can make a one-day visit with them. We have three doctors and four nurses, one of whom will then be assigned the visit.’
Older patients who are at home do not want to go to the hospital. “In fact, when it’s really necessary, we have to tell them, ‘You know, I really wish I could get you all the treatment here, but I can’t,'” Patel said. “‘The best thing for you is to go to the hospital and I’ll see you directly or talk to the emergency room doctors so you don’t have to wait so long.’
The Department of Geriatrics and Supportive Medicine began integrating community health workers into the care of older patients by partnering with a San Antonio nonprofit called House of Neighborly Service, which had two CHWs. A grant called Impact San Antonio aided the process.
Over time, the department added its own promoters as well as nurse practitioners. A grant from the Nancy Smith Hurd Foundation enabled the hiring of the first promoters.
The Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases at UT Health San Antonio helped the division recruit another promoter.
Patients who require supportive care are often seen.
“They are very frail and burdened with advanced dementia, heart disease, heart failure or COPD, and they really don’t want to go to hospital,” Patel said.
“That’s why we often see them being admitted to our supportive care program,” she said. “Once we have a care plan, the promoter makes sure they follow it.”
Each promoter follows about 10 to 12 patients monthly. When the patient’s care is stabilized, she moves on to other patients who need more frequent visits.
Promoter visits are documented in the practice’s electronic medical record. This reflects the integration of promoters into the geriatric and supportive care team.
source:
University of Texas Health Science Center at San Antonio
Journal reference:
Patel, NK, et al. (2023). Clinicians and promoters team up to provide home-based primary care for frail older adults. Annals of Family Medicine. doi.org/10.1370/afm.2998.